2018 Health Insurance Plans - ebview.com · 2018 Health Insurance Plans Who can enroll? for Retired Members Retired Members, surviving spouses/ partners, and eligible dependents When

2018 Health Insurance Plans

For Retired SDCERA Members

Strength. Service. Commitment.

San Diego County Employees Retirement Association

Table of Contents

Eligibility ...........................................................................................1

Enrollment in a plan ...........................................................................1

Health Insurance Allowance ...............................................................2

2018 Monthly Premiums .....................................................................3

Medical Plans ....................................................................................4

Dental Plans .......................................................................................9

Notice of Creditable Coverage ..........................................................10

COBRA Continuation ......................................................................11

Legal Notices ...................................................................................13

2018 Health Insurance Plans for Retired Members

Who can enroll?

Retired Members, surviving spouses/partners, and eligible dependents

When can I enroll?

Annually during Open Enrollment, or within 30 days of an eligible event such as retirement

Do I need to re-enroll every year?

No, your current

SDCERA‑sponsored

plan election(s) will renew automatically if you take no action during Open Enrollment

If you are enrolled in an SDCERA-sponsored health plan, your current plan election(s) will automatically renew for the 2018 calendar year, unless you request a change.

Eligibility

SDCERA sponsors group medical and dental insurance plans for retired Members and their eligible dependents. In addition, if you are the surviving spouse/partner or dependent of a deceased SDCERA Member and you receive a monthly SDCERA retirement benefit, the plans are also available to you. Eligible dependents include a spouse or registered domestic partner and children under age 26.

Premium(s) and applicable fees for all SDCERA‑sponsored health plans, including coverage for your dependent(s), will be deducted from your monthly retirement benefit. If your monthly benefit does not cover the cost of the plan(s) you select, the SDCERA Retiree Health Program Service Center will contact you to set up automatic debit from your checking or savings account.

Plans provide coverage in both California and out‑of‑state service areas, but service areas vary by plan. Please contact the plan to verify that you live within its service area before enrolling. Premiums and types of medical plans vary based on Medicare eligibility. Dental plans are available to Members regardless of age and Medicare eligibility. SDCERA does not offer plans that provide coverage to Members living outside of the United States.

Enrollment in a plan

You may enroll or make changes to your current SDCERA‑sponsored plan selection during Open Enrollment from November 1 through November 22, 2017. Enrollment or changes outside of the annual Open Enrollment period are limited to qualifying life events (see Page 2). If you wish to continue your current election(s), you do not need to do anything during Open Enrollment; your current plan election(s) will renew automatically. If you change your plan, or enroll for the first time, allow 30 days from the effective date for the carrier to recognize your coverage. Plan ahead for any necessary prescriptions or care you may require.

2018 Health Insurance Plans1

Enrollment or changes outside of the annual Open Enrollment period are limited. You can cancel coverage for yourself or your dependents at any time. You may be eligible to enroll or make changes within 30 days if you have a qualifying life event noted below:

• retire

• become eligible for Medicare (or your dependent becomes eligible)

• add a dependent due to marriage, domestic partner registration, birth, adoption or placement for adoption

• move outside your plan’s service area

• lose eligibility for coverage, such as conclusion of COBRA or Cal‑COBRA

• lose eligibility for other coverage (or if the employer stops contributing toward your or your dependents’ other coverage), or

• lose eligibility (not due to termination for cause) for Medicaid, Medi‑Cal, Children’s Health Insurance Program (CHIP), Healthy Families Program, or Access for Infants and Mothers Program (you must request enrollment within 60 days)

If you are (or your dependent is) eligible for Medicare and the other is not, you can enroll in separate plans (Medicare and non‑Medicare) with the same carrier.

If you are (or your dependent is) turning 65 in 2018 and will become eligible for Medicare, the SDCERA Health Plans Service Center will send correspondence to your mailing address approximately 90 days prior to your 65th birthday outlining necessary steps to enroll in Medicare and providing information about SDCERA‑sponsored Medicare plans. In the meantime, you may enroll in a non‑Medicare plan through SDCERA.

To enroll in medical and/or dental plans, please visit www.sdcera.org, click on Retiree Health Program and then “Enrollment”, and follow the steps outlined to obtain a copy of the SDCERA Health Insurance Plans Enrollment form. This form is used to process your request, which includes enabling premium deductions to cover the cost of plan premiums and using your address for health zone coverage verification purposes. Please note, enrollment in some of the SDCERA‑sponsored Medicare plans requires a separate carrier‑specific form. More information is available on the Retiree Health Program page. You may submit your form requesting enrollment in an SDCERA‑sponsored plan online or by mailing or faxing your completed form to the SDCERA Health Plans Service Center.

Tier I and Tier II Members: Health Insurance Allowance

The Health Insurance Allowance (HIA) helps offset the cost of premiums for medical, dental and prescription plans. In addition to the allowance, $93.50 may be reimbursed to offset the cost of Medicare Part B. You are eligible for HIA if you are a retired Tier I or Tier II Member who has at least 10 years of SDCERA service credit or is receiving a disability retirement. Monthly allowance amounts range from $200 to $400. The HIA is not a vested SDCERA benefit and is not guaranteed. The allowance may be reduced or discontinued at any time.

To use your HIA towards the cost of a medical, dental and/or prescription plan not sponsored by SDCERA, complete the Health Insurance Allowance Request form. You must enroll in the program each year to be reimbursed.

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Medical plan coverage details and premiums begin on Page 4 of this booklet. Dental coverage details and premiums are on page 9. The premiums shown for medical and dental plans are per person, per month and do not include an administrative fee of $5.16.


2018 Health Insurance Plans 3

2018 Monthly Premiums

Plan Monthly Premium Per Person

Health Net HMO $1,510.19

Kaiser Permanente HMO $859.07

UHC Signature Value HMO $2,334.18


Health Net HMO $610.99

Health Net Seniority Plus $286.48

Kaiser Permanente Senior Advantage $270.30

UHC Group Medicare Advantage $282.26

UHC Senior Supplement $504.93

Non-Medicare Plans

Medicare Plans


CIGNA Dental Care (DHMO) $17.24

Delta Dental PPO $43.35

Dental Plans

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Non-Medicare plansGenerally for those under age 65These plans are only available in the state of California.

Health Net HMO

1.800.522.0088Group 57358‑A

www.healthnet.com

IMPORTANT NOTES HMO plan

SDCERA‑sponsored medical plans do not have overall annual or lifetime limits. Service area varies by plan. Please confirm you live within a plan’s service area before enrolling. Refer to each plan’s coverage documents for exact terms and conditions of coverage. If there is a discrepancy between this summary chart and the plan documents, the plan documents will govern.

You are required to use the primary care physician you

select from a list of providers.

$1,510.19

Annual deductible Any applicable deductible must be met before coverage shown is effective. None

Ambulance Requires preauthorization. Covered in fullAnesthesia Covered in full

Chiropractic visit

If covered, services generally include initial examinations; additional visits for treatment; x‑ray and laboratory fees when prescribed.

Preauthorization may be required.

Not covered

Durable medical equipment Covered in full

Emergency care

Includes accidental injury and acute illness; the copayment shown is when visiting an

emergency room and is waived if you are admitted.

$35

Fitness club membership Discounts available

Hearing care and hearing aids

Preventive screening covered in full; all other $20 per exam.

No coverage for hearing aids.

Home health care Requires a physician’s prescription.Covered in full up to 30 days; $10 copayment starts on the 31st day

after the 1st visit.

Hospice care Covered in fullHospital room and board Coverage is for a semi‑private room. Covered in fullLaboratory fees Covered in fullPhysician care (doctor visits) unrelated to hospitalization

The copayments shown are for office visits unrelated to hospitalization. $20 per office visit

Physician care (doctor visits) due to hospitalization Coverage shown is for visits due to hospitalization. Covered in full

Prescription medications from a mail order sponsored by the carrier

The copayments in all cases are for the number of days shown.

$20 generic, $60 brand name, $90 non‑formulary. 90‑day supply.

Prescription medications from a pharmacy

Unless noted, non‑formulary prescriptions are covered by the same copayments

when deemed medically necessary.

$10 generic, $30 brand name, $45 non‑formulary.30‑day supply.

Psychiatric care (inpatient)An asterisk (*) indicates the plan will cover this care

in full for diagnoses covered under the Mental Health Parity Act.

*Covered in fullNo limit on days

Psychiatric care (outpatient) $20 per visit, unlimited visits

Rehabilitation therapy Physical, speech, occupational, pulmonary, and cardiac Covered in full

Skilled nursing facility Covered in full up to 100 days

Surgery (inpatient) Covered in fullSurgery (outpatient) Covered in fullUrgent care An asterisk (*) indicates non‑emergency. $35

Vision care and eyewear

$20 per exam; No coverage for eyewear.

X-rays Covered in full

Monthly premium per person


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UHC Signature Value HMO1.800.624.8822Group 004501

www.myuhc.com

HMO plan

You are required to use the primary care physician you select from a list of providers.

$2,334.18

None

Covered in fullCovered in full

$15 per visit, up to 20 visits.

Covered in full

$50

Discounts available

$20 per exam; Hearing aids are covered in full up to $5,000 every 36 months.

Covered in full up to 100 visits per year

Covered in fullCovered in fullCovered in full

$20 per office visit

Covered in full

$30 generic, $60 brand name.90‑day supply.

$15 generic, $30 brand name.30‑day supply.

*Covered in fullNo limit on days

$20 per visit, unlimited visits

$20 copay

Covered in full up to 100 consecutive calendar days from first treatment


$50$20 per exam;

No coverage for eyewear.Covered in full

Kaiser Permanente HMO1.800.464.4000Group 104302

www.kp.org

HMO plan

You are required to use Kaiser Permanente physicians and facilities. A higher premium will apply if you enroll in

this plan when eligible for Medicare.

$859.09

None


$10 per visit, up to 20 visits

Covered in full

$25

Discounts available

Preventive screening covered in full; All other $20 per exam. No coverage for hearing aids.

Covered in full up to 100 days

Covered in fullCovered in fullCovered in full

$20 per office visit

Covered in full

$15 generic, $30 brand name. Up to a 100‑day supply.

$15 generic, $30 brand name. Up to a 100‑day supply. Specialty drugs up to 30 days.

*Covered in fullUnlimited visits

$20 per visit, unlimited visits

$0 inpatient,

Covered in full up to 100 days

Covered in full$20 copayment

$20*No charge for routine eye exams

with a plan optometrist. $20/exam.

Covered in full

SDCERA-sponsored Medicare plans

Although you may be enrolled in Medicare Part A and Part B, you may still have medical expenses not covered by Medicare; therefore, enrolling in an additional insurance plan such as an SDCERA‑sponsored medical plan may help pay for expenses that Medicare does not cover.

As long as you are covered by an SDCERA‑sponsored medical plan, you will have the option of joining a Medicare drug plan in the future—without a penalty. SDCERA‑sponsored medical plans meet the Centers for Medicare and Medicaid Services (CMS) creditable coverage guidelines. The Notice of Creditable Coverage on Page 10 of this booklet provides you with the documentation you need to prove that you have had creditable coverage through an SDCERA‑sponsored plan. This notice protects you from penalty charges and allows you to join a Medicare drug plan in the future (if you so decide).

SDCERA offers three types of Medicare health plans for Members covered by Medicare Part A and Part B. SDCERA‑sponsored plans include comprehensive medical coverage as well as the Medicare prescription drug coverage; therefore, if you enroll in an SDCERA‑sponsored plan, your drug coverage will be provided through the SDCERA‑sponsored plan you select. If you enroll in a separate Medicare prescription plan (Part D), you and your dependents will be disenrolled from the SDCERA-sponsored plan.

Medicare Supplement plans allow you to keep your Medicare benefits and use any physician or facility that accepts Medicare.

Medicare HMO plans coordinate their coverage with Medicare. You may also use your Medicare card to obtain services outside

your health plan.

Medicare Advantage plans require your Medicare Part A and Part B to be assigned to a health plan.

Refer to the Medicare Information page on the Retiree Health Program page of www.sdcera.org for more information about the types of Medicare health plans.

If you are eligible for Medicare, but your dependent is not (or if you are not eligible for Medicare and your dependent is), and you both want to enroll in SDCERA‑sponsored plans, you may enroll in separate plans with the same carrier.

You must submit a copy of both sides of your signed Medicare identification card to confirm your eligibility for enrollment in an SDCERA‑sponsored Medicare plan. If you have submitted a copy in the past, you do not need to submit another copy. If you are (or your dependent is) newly enrolled in Medicare Part A and Part B, please submit a copy of the signed card to the SDCERA Health Plans Service Center when you receive it.

If you are (or your dependent is) covered by Medicare Part A only or Medicare Part B only, different premiums may apply. If this situation affects you, contact the SDCERA Retiree Health Program Service Center at 1.866.751.0256 to confirm your monthly premium.

For information about the Medicare program, enrollment deadline or to contact Medicare, visit www.medicare.gov or call 1.800.633.4227.

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Medicare information for SDCERA-sponsored plans


Medicare plansGenerally for those over age 65

Health Net HMO Health Net Seniority Plus Kaiser Permanente Senior Advantage

UHC Group Medicare Advantage UHC Senior Supplement

1.800.522.0088Group 57358‑B

www.healthnet.com

1.800.275.4737Group 57358‑S

www.healthnet.com

Customer service—1.800.457.8506Prospective Member—1.877.714.0178

Group CA: 004497; AZ: 060499; NV: 667201www.uhcretiree.com


Group 05408www.uhcretiree.com

1.800.464.4000Group 104302‑00

www.kp.orgIMPORTANT NOTES Medicare HMO plan Medicare Advantage plan Medicare Advantage plan Medicare Advantage plan Medicare Supplement plan


Benefits coordinated with Medicare (primary); may use Medicare outside of network. You must use a primary care

physician from the providers list for HMO to cover services.

Medicare benefit must be assigned to the plan. You

are required to use the Health Net physician you select

from a list of providers.

Medicare benefit must be assigned to the plan, or a higher premium and traditional Kaiser HMO benefits

apply. You are required to use Kaiser Permanente physicians and facilities.

This plan provides coverage in California, Arizona and Nevada. Medicare benefit must be assigned to the plan. You are

required to use the primary care physician you select from a list of providers.

This plan is available nationwide. You may use any physician or facility

that accepts Medicare.

Monthly premium per person $610.99 $286.48 $270.30 $282.26 $504.93

Annual deductible Applicable deductible must be met before coverage shown is effective. None None None None None

Ambulance Requires preauthorization. Covered in full Covered in full Covered in full Covered in full Covered in full. No preauthorization required.

Anesthesia Covered in full Covered in full Covered in full Covered in full Covered in full

Chiropractic visit

If covered, services generally include initial examinations; additional

visits for treatment; x‑ray and laboratory fees when prescribed.


Not covered $5 per visit up to 20 visits through American Specialty Health Network $10 per visit, up to 20 visits $5 per visit, up to 20 visits Spinal manipulation covered; $0 per visit.

Other services generally not covered.

Durable medical equipment Covered in full Covered in full Covered in full Covered in full Covered in full

Emergency care

Includes accidental injury and acute illness; the copayment shown is when

visiting an emergency room and is waived if you are admitted.

$35 $20 $20 $20Covered in full in the U.S.;

$250 deductible outside of the U.S.,

20% thereafter.

Fitness club membership Discounts available Silver & Fit Discounts available Silver Sneakers Fitness membership Silver Sneakers Fitness membership




$20 per exam, 2 standard hearing aids every 36 months covered in full

$10 per examNo coverage for hearing aids.

$0 per exam; hearing aids covered up to $500 every 36 months.

Exams covered; $0 per visit for Medicare covered exams. Hearing aids not covered.

Home health care Requires a physician’s prescription.Covered in full up to 30 days;

$10 copayment starts on the 31st day after the 1st visit.

Covered in full Covered in full. Refer to evidence of coverage from the plan. Covered in full Covered in full

Hospice care Covered in full Covered per Medicare guidelines Covered in full Covered per Medicare guidelines Covered in full

Hospital room and board Coverage is for a semi‑private room. Covered in full Covered in full Covered in full Covered in full Covered in full

Laboratory fees Covered in full Covered in full Covered in full Covered in full Covered in full

Physician care (doctor visits) unrelated to hospitalization

Copayments shown are for office visits unrelated to hospitalization. $20 per office visit $20 per office visit $10 per office visit $20 per office visit Covered in full

Physician care (doctor visits) due to hospitalization

Coverage shown is for visits due to hospitalization. Covered in full Covered in full Covered in full Covered in full Covered in full


Copayments are for the number of days shown. Copays may vary when the Medicare Part D Catastrophic

Coverage stage is reached.

$30 generic, $60 brand name, $100 non‑formulary. 90‑day supply. Administered

by SilverScript.

$30 generic, $60 brand name, $90 non‑formulary.

90‑day supply.

$10 generic, $20 brand nameUp to a100‑day supply.

$20 generic, $60 brand name, $60 non‑preferred brand formulary.

90‑day supply.

$20 generic, $70 brand name; $100 non‑preferred brand formulary.

90‑day supply.

Prescription medications from a pharmacy before reaching Medicare Part D Catastrophic Coverage Stage

Unless noted, non‑formulary prescriptions are covered by the same copayments when deemed

medically necessary.


30‑day supply. Administered by SilverScript.


$10 generic, $20 brand nameUp to a 100‑day supply.


30‑day supply.


30‑day supply.

Psychiatric care (inpatient)

An asterisk (*) indicates the plan will cover this care in full for diagnoses covered under the Mental Health

Parity Act.

*Covered in full Covered in full *Covered in fullUnlimited visits

Covered per Medicare guidelines up to 190 days per lifetime Covered in full up to 150 days

Psychiatric care (outpatient) $20 per visit $20 per visit $10 per visit, unlimited visits $20 per visit Covered in full

Rehabilitation therapy Physical, speech, occupational, pulmonary, and cardiac Covered in full No copay for

Medicare‑covered services $0 inpatient; $10 per visit outpatient $0 copay Covered in full

Skilled nursing facility Covered in full up to 100 days Covered in full up to 100 days Covered in full up to 100 days Covered in full up to 100 days Covered in full up to 100 days

Surgery (inpatient) Covered in full Covered in full Covered in full Covered in full Covered in full

Surgery (outpatient) Covered in full Covered in full $10 per procedure Covered in full Covered in full

Urgent care An asterisk (*) indicates non‑emergency. $35 $20 $10* $10 copay (in‑ and out‑of‑network) Covered in full


$20 per exam. No coverage for eyewear.

$20 per exam. $100 paid for eyewear every 2 years.

$10 per exam. $150 allowance for eyewear every 2 years.

$20 per exam.$75 per eyewear every 2 years.

$0 per Medicare‑covered exam. Medicare‑covered eyewear is reimbursed. Non‑Medicare is not covered.

X-rays Covered in full Covered in full Covered in full Covered in full Covered in full

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Medicare plansgenerally for those over age 65

Health Net HMO Health Net Seniority Plus Kaiser Permanente Senior Advantage

UHC Group Medicare Advantage UHC Senior Supplement

1.800.522.0088Group 57358‑B

www.healthnet.com

1.800.275.4737Group 57358‑S

www.healthnet.com


Group CA: 004497; AZ: 060499; NV: 667201www.uhcretiree.com


Group 05408www.uhcretiree.com

1.800.464.4000Group 104302‑00

www.kp.orgIMPORTANT NOTES Medicare HMO plan Medicare Advantage plan Medicare Advantage plan Medicare Advantage plan Medicare Supplement plan


Benefits coordinated with Medicare (primary); may use Medicare outside of network. You must use a primary care

physician from the providers list for HMO to cover services.

Medicare benefit must be assigned to the plan. You

are required to use the Health Net physician you select

from a list of providers.

Medicare benefit must be assigned to the plan, or a higher premium and traditional Kaiser HMO benefits

apply. You are required to use Kaiser Permanente physicians and facilities.

This plan provides coverage in California, Arizona and Nevada. Medicare benefit must be assigned to the plan. You are

required to use the primary care physician you select from a list of providers.

This plan is available nationwide. You may use any physician or facility

that accepts Medicare.

Monthly premium per person* $610.99 $286.48 $270.30 $282.26 $504.93

Annual deductible Applicable deductible must be met before coverage shown is effective. None None None None None

Ambulance Requires preauthorization. Covered in full Covered in full Covered in full Covered in full Covered in full. No preauthorization required.

Anesthesia Covered in full Covered in full Covered in full Covered in full Covered in full

Chiropractic visit

If covered, services generally include initial examinations; additional

visits for treatment; x‑ray and laboratory fees when prescribed.


Not covered $5 per visit up to 20 visits through American Specialty Health Network $10 per visit, up to 20 visits $5 per visit, up to 20 visits Spinal manipulation covered; $0 per visit.

Other services generally not covered.

Durable medical equipment Covered in full Covered in full Covered in full Covered in full Covered in full

Emergency care

Includes accidental injury and acute illness; the copayment shown is when

visiting an emergency room and is waived if you are admitted.

$35 $20 $20 $20Covered in full in the U.S.;

$250 deductible outside of the U.S.,

20% thereafter.

Fitness club membership Discounts available Silver & Fit Discounts available Silver Sneakers Fitness membership Silver Sneakers Fitness membership




$20 per exam, 2 standard hearing aids every 36 months covered in full

$10 per examNo coverage for hearing aids.

$0 per exam; hearing aids covered up to $500 every 36 months.

Exams covered; $0 per visit for Medicare covered exams. Hearing aids not covered.

Home health care Requires a physician’s prescription.Covered in full up to 30 days;

$10 copayment starts on the 31st day after the 1st visit.

Covered in full Covered in full. Refer to evidence of coverage from the plan. Covered in full Covered in full

Hospice care Covered in full Covered per Medicare guidelines Covered in full Covered per Medicare guidelines Covered in full

Hospital room and board Coverage is for a semi‑private room. Covered in full Covered in full Covered in full Covered in full Covered in full

Laboratory fees Covered in full Covered in full Covered in full Covered in full Covered in full

Physician care (doctor visits) unrelated to hospitalization

Copayments shown are for office visits unrelated to hospitalization. $20 per office visit $20 per office visit $10 per office visit $20 per office visit Covered in full

Physician care (doctor visits) due to hospitalization

Coverage shown is for visits due to hospitalization. Covered in full Covered in full Covered in full Covered in full Covered in full


Copayments are for the number of days shown. Copays may vary when the Medicare Part D Catastrophic

Coverage stage is reached.

$30 generic, $60 brand name, $100 non‑formulary. 90‑day supply. Administered

by SilverScript.


90‑day supply.

$10 generic, $20 brand nameUp to a100‑day supply.


90‑day supply.


90‑day supply.

Prescription medications from a pharmacy before reaching Medicare Part D Catastrophic Coverage Stage

Unless noted, non‑formulary prescriptions are covered by the same copayments when deemed

medically necessary.


30‑day supply. Administered by SilverScript.


$10 generic, $20 brand nameUp to a 100‑day supply.


30‑day supply.


30‑day supply.

Psychiatric care (inpatient)

An asterisk (*) indicates the plan will cover this care in full for diagnoses covered under the Mental Health

Parity Act.

*Covered in full Covered in full *Covered in fullUnlimited visits

Covered per Medicare guidelines up to 190 days per lifetime Covered in full up to 150 days

Psychiatric care (outpatient) $20 per visit $20 per visit $10 per visit, unlimited visits $20 per visit Covered in full

Rehabilitation therapy Physical, speech, occupational, pulmonary, and cardiac Covered in full No copay for

Medicare‑covered services $0 inpatient; $10 per visit outpatient $0 copay Covered in full

Skilled nursing facility Covered in full up to 100 days Covered in full up to 100 days Covered in full up to 100 days Covered in full up to 100 days Covered in full up to 100 days

Surgery (inpatient) Covered in full Covered in full Covered in full Covered in full Covered in full

Surgery (outpatient) Covered in full Covered in full $10 per procedure Covered in full Covered in full

Urgent care An asterisk (*) indicates non‑emergency. $35 $20 $10* $10 copay (in‑ and out‑of‑network) Covered in full


$20 per exam. No coverage for eyewear.

$20 per exam. $100 paid for eyewear every 2 years.

$10 per exam. $150 allowance for eyewear every 2 years.

$20 per exam.$75 per eyewear every 2 years.

$0 per Medicare‑covered exam. Medicare‑covered eyewear is reimbursed. Non‑Medicare is not covered.

X-rays Covered in full Covered in full Covered in full Covered in full Covered in full

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8 2018 Health Insurance Plans


Dental plansfor retired Members and dependents

CIGNA Dental Care (DHMO) Delta Dental PPO

1.800.244.6224Group number 3217340

www.cigna.com

This plan is available in 39 of 50 states. States without coverage: AK, HI, ME,

MT, ND, NE, NM, RI, SD, VT and WY.

1.800.765.6003Group number 02472‑00001

www.deltadentalins.com

This plan provides coverage nationwide.

Refer to each plan’s coverage documents for exact terms and conditions of coverage. If there is a discrepancy between this summary chart and the plan documents, the plan documents will govern.

Annual deductibleAny applicable deductible must be met before coverage shown is effective unless noted.

None

IN-NETWORK OUT-OF-NETWORK*

$50 per person $50 per person

Annual maximum benefit No maximum $1,500 per person $1,000 per person

Basic and restorative servicesFillings, sealants, simple extractions

Copayments vary by service; refer to the schedule of patient charges available

from the plan.

80% of PPO contracted fee after deductible has

been met


been met

Diagnostic and preventive servicesEmergency treatment for pain, oral exams, prophylaxis, space maintainers, x‑rays

100% for most services

100% of PPO contracted fee with no deductible

100% of PPO contracted fee with no deductible

Other basic and major servicesBridges, crowns, dentures, endodontics, implants, oral surgery, periodontal treatment


from the plan.

Implants are not covered under the DHMO plan; however, implant crowns

are covered.


been met


been met

OrthodontiaFor adults and eligible dependent children


from the plan.

50% of PPO contracted fee; $1,000 lifetime

maximum, per person for orthodontia services.

50% of PPO contracted fee; $1,000 lifetime

maximum, per person for orthodontia services.

SDCERA-sponsored dental plansWhen deciding which dental plan will provide the best coverage for you, consider the differences between a dental health maintenance organization (DHMO) plan and a dental preferred provider organization (PPO) plan.

DHMO plans contract with their own network of dentists and all care is coordinated by the dental office you select. You may change your dental office at any time. If you receive care (other than emergency services) that is not coordinated by your dental office, you are required to pay the full cost for the services you receive. The cost of your out‑of‑pocket expense in a DHMO dental plan is based on a schedule of patient charges. There are no charges for many diagnostic and preventive services, and most other types of service require you to pay a copayment.

Dental PPO plans give you the flexibility to have all covered services provided by the dentist of your choice; however, you pay less if you select a dentist within the network the plan has contracted with to provide services, because network dentists charge patients pre‑negotiated discount rates for services. If you choose to see an out‑of‑network dentist, the reimbursement amount is based on the network’s regional schedule of benefits for a geographic area. If your dentist charges more than a network dentist’s allowed fee, you are responsible for paying the difference.

To enroll in a dental plan listed below and establish payment deductions to cover the cost of plan premiums, complete and submit the SDCERA Health Insurance Plans Enrollment form on the Retiree Health Program page of www.sdcera.org.

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*If you go out‑of‑network, visit a Delta Dental Premier dentist for lower costs.

Notice of Creditable Coverage

Important notice about your prescription drug coverage and MedicareThe prescription drug coverage you have under your SDCERA‑sponsored medical plan for retired Members is expected to pay out, on average, at least as much as the standard Medicare prescription drug coverage will pay.

If you decide to join a Medicare drug plan, your current SDCERA-sponsored medical and prescription drug coverage will end for you and all covered dependents. If you decide to join a Medicare drug plan and drop your current SDCERA‑sponsored coverage, be aware that you and your dependents will be unable to get this coverage back until the next Open Enrollment period.

Members enrolled in an SDCERA‑sponsored prescription drug plan receive notice of creditable coverage annually. You may receive this notice at other times in the future, such as before the next period during which you may enroll in Medicare prescription drug coverage, if SDCERA‑sponsored plan coverage changes, or upon your request.


11

COBRA Continuation Coverage

The Consolidated Omnibus Budget Reconciliation Act (COBRA) provides retired Members,

non‑Member payees, and their dependents who lose SDCERA‑sponsored coverage the

right to continue medical and dental coverage for limited periods of time due to certain

COBRA‑qualifying events.

Electing COBRA coverageIf you are eligible to elect COBRA continuation coverage due to a qualifying event, you have

60 days (from the date of the COBRA election notice or the date you lose coverage, whichever

is later) to elect COBRA continuation coverage.

COBRA Qualifying eventsCOBRA defines a qualifying event as the loss of health plan coverage that is attributable

to death of the Member, divorce, legal separation, annulment or dependent(s) ineligibility

(for instance, your dependent(s) no longer satisfies the requirements for coverage, such as

attainment of age 26).

Each individual who is affected by the qualifying event may independently elect continuation

coverage. This means that if you and your dependents are entitled to elect continuation

coverage, you each may decide separately whether to do so. The covered Member or the

spouse/registered domestic partner is allowed to elect on behalf of any dependent children or

on behalf of all qualified beneficiaries; COBRA coverage is limited to a maximum of 36 months

and the following terms and conditions apply:

• COBRA premiums are calculated based on current monthly medical or dental plan

rates plus a two percent administrative fee.

• You may only continue the coverage that was in effect on the date of the

qualifying event.

• Coverage is extended only to those individuals covered at the time of the

qualifying event.


12

COBRA participants are subject to the same plan coverage levels and administrative

rules (e.g., adding dependents and changing or canceling coverage) that apply to

non‑COBRA participants.

COBRA is provided subject to your eligibility for coverage under the law and the plan.

SDCERA reserves the right to terminate your continuation coverage retroactively if you

are later determined to be ineligible.

Federal law places responsibility upon the Member or the Member’s eligible dependent(s)

to notify within 60 calendar days of death, divorce, legal separation, annulment or

dependent’s ineligibility. If you or your eligible dependent(s) do not notify the SDCERA

Health Plans Service Center of the qualifying event within the required time frame, you

and your dependents will be ineligible for COBRA. Other forms of notice will not bind

the plan.

COBRA Continuation Coverage (cont.)

You will be ineligible for COBRA coverage if you do not notify the SDCERA

Health Plans Service Center within 60 days of a qualifying event.


13

SDCERA Retiree Health Program administration credit and fees

SDCERA Retiree Health Program administration feesThe administrative expenses of the health benefit program are paid by each plan participant. The health

benefit program expenses are divided equally among all participants, resulting in a monthly fee per person

for each plan in which they enroll (applicable to both medical and dental plans). This fee is applicable to

SDCERA‑sponsored plans and the Health Insurance Allowance program. The monthly administrative fee is

$5.16 for the 2018 plan year.

Patient Centered Outcomes Research Institute (PCORI)Federal law requires SDCERA to pay the Patient Centered Outcomes Research Institute (PCORI) fee

for each health plan participant. This fee, paid to the Internal Revenue Service (IRS), is intended to

fund a federal research institute that publishes guidelines for improving public health. Tier I and Tier II

members receiving the Health Insurance Allowance or Medicare Part B Reimbursement funds in 2017

will be charged this fee. The federal government determines the current‑year PCORI fee in October.

Once the fee is determined, SDCERA will deduct the fee from your retirement benefit.

Legal notices


Legal Notices

14

CHIP/Medicaid NoticePremium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)

If you or your children are eligible for Medicaid or CHIP and you are eligible for health

coverage from your employer, your state may have a premium assistance program that can

help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your

children aren’t eligible for Medicaid or CHIP, you may not be eligible for these premium

assistance programs but you may be able to buy individual insurance coverage through the

Health Insurance Marketplace. For more information, visit www.healthcare.gov.

If you or your dependents are already enrolled in Medicaid or CHIP and you live in a

state listed below on pages 15‑18, contact your state Medicaid or CHIP office to find out if

premium assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think

you or any of your dependents might be eligible for either of these programs, contact your

state Medicaid or CHIP office or dial 1.877.KIDS NOW or www.insurekidsnow.gov. If you

qualify, ask your state if it has a program that might help you pay the premiums for an

employer‑sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP,

as well as eligible under your employer plan, your employer must allow you to enroll in

your employer plan if you aren’t already enrolled. This is called a “special enrollment”

opportunity, and you must request coverage within 60 days of being determined eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the

Department of Labor at www.askebsa.dol.gov or call 1.866.444.EBSA (3272).



Medicaid Contact List by State

ALABAMA – MedicaidWebsite: http://myalhipp.com/

Phone: 1‑855‑692‑5447

ALASKA – MedicaidWebsite: http://dhss.alaska.gov/dpa/Pages/medicaid/default.aspx

Phone (Outside of Anchorage): 1‑800‑780‑9972 / Phone (Anchorage): 907‑465‑2680

COLORADO – Medicaid Medicaid Website: http://www.colorado.gov/hcpf

Medicaid Customer Contact Center: 1‑800‑221‑3943

FLORIDA – MedicaidWebsite: http://flmedicaidtplrecovery.com/hipp/

Phone: 1‑877‑357‑3268

GEORGIA – Medicaid Website: http://dch.georgia.gov/medicaid ‑ Click on Health Insurance Premium Payment

(HIPP) Phone: 404‑656‑4507

INDIANA – Medicaid Healthy Indiana Plan for low‑income adults 19‑64 Website: http://www.hip.in.gov

Phone: 1‑877‑438‑4479

All other Medicaid Website: http://www.indianamedicaid.com

Phone 1‑800‑403‑0864

IOWA – Medicaid Website: http://www.dhs.state.ia.us/hipp/

Phone: 1‑888‑346‑9562

KANSAS – MedicaidWebsite: http://www.kdheks.gov/hcf/

Phone: 1‑785‑296‑3512

KENTUCKY – MedicaidWebsite: http://chfs.ky.gov/dms/default.htm

Phone: 1‑800‑635‑2570

15


LOUISIANA – MedicaidWebsite: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331

Phone: 1‑888‑342‑6207

MAINE – MedicaidWebsite: http://www.maine.gov/dhhs/ofi/publicassistance/index.html

Phone: 1‑800‑442‑6003

TTY: Maine relay 711

NEW JERSEY – Medicaid and CHIPMedicaid Website: http://www.state.nj.us/humanservices/dmahs/clients/medicaid/

Medicaid Phone: 609‑631‑2392

CHIP Website: http://www.njfamilycare.org/index.html

CHIP Phone: 1‑800‑701‑0710

NEW YORK – Medicaid Website: http://www.nyhealth.gov/health_care/medicaid/

Phone: 1‑800‑541‑2831

NORTH CAROLINA – Medicaid Website: http://www.ncdhhs.gov/dma

Phone: 919‑855‑4100

MASSACHUSETTS – Medicaid and CHIPWebsite: http://www.mass.gov/MassHealth

Phone: 1‑800‑462‑1120

MINNESOTA – MedicaidWebsite: http://mn.gov/dhs/ma/

Phone: 1‑800‑657‑3739

MISSOURI – MedicaidWebsite: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm

Phone: 573‑751‑2005

MONTANA – MedicaidWebsite: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP

Phone: 1‑800‑694‑3084

NEBRASKA – MedicaidWebsite: http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/

accessnebraska_index.aspx

Phone: 1‑855‑632‑7633

2018 Health Insurance Plans 17

NEVADA – MedicaidMedicaid Website: http://dwss.nv.gov/

Medicaid Phone: 1‑800‑992‑0900

NEW HAMPSHIRE – MedicaidWebsite: http://www.dhhs.nh.gov/oii/documents/hippapp.pdf

Phone: 603‑271‑5218

NORTH DAKOTA – MedicaidWebsite: http://www.nd.gov/dhs/services/medicalserv/medicaid/

Phone: 1‑844‑854‑4825

OKLAHOMA – Medicaid and CHIPWebsite: http://www.insureoklahoma.org

Phone: 1‑888‑365‑3742

OREGON – Medicaid Website: http://www.oregonhealthykids.gov http://www.hijossaludablesoregon.gov

Phone: 1‑800‑699‑9075

PENNSYLVANIA – MedicaidWebsite: http://www.dhs.pa.gov/hipp

Phone: 1‑800‑692‑7462

RHODE ISLAND – MedicaidWebsite: http://www.eohhs.ri.gov/

Phone: 401‑462‑5300

SOUTH CAROLINA – MedicaidWebsite: http://www.scdhhs.gov

Phone: 1‑888‑549‑0820

SOUTH DAKOTA - MedicaidWebsite: http://dss.sd.gov

Phone: 1‑888‑828‑0059

TEXAS – MedicaidWebsite: http://gethipptexas.com/

Phone: 1‑800‑440‑0493

UTAH – Medicaid and CHIPWebsite: Medicaid: http://health.utah.gov/medicaid

CHIP: http://health.utah.gov/chip

Phone: 1‑877‑543‑7669


VERMONT– MedicaidWebsite: http://www.greenmountaincare.org/

Phone: 1‑800‑250‑8427

VIRGINIA – Medicaid and CHIPMedicaid Website: http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1‑855‑242‑8282

CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm

CHIP Phone: 1‑855‑242‑8282

WASHINGTON – MedicaidWebsite: http://www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx

Phone: 1‑800‑562‑3022 ext. 15473

WEST VIRGINIA – MedicaidWebsite: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Pages/default.aspx

Phone: 1‑877‑598‑5820, HMS Third Party Liability

WISCONSIN – Medicaid and CHIPWebsite: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf

Phone: 1‑800‑362‑3002

WYOMING – MedicaidWebsite: https://wyequalitycare.acs‑inc.com/

Phone: 1‑855‑294‑2127

To see if any other states have added a premium assistance program since January 31, 2016,

or for more information on special enrollment rights, contact either:

U.S. Department of Labor

Employee Benefits Security Administration

www.dol.gov/ebsa1.866.444.EBSA (3272)

U.S. Department of Health and Human Services

Centers for Medicare & Medicaid Services

wwww.cms.hhs.gov 1.877.267.2323, Menu Option 4, Ext. 61565

Physician Designation Notice

The SDCERA HMO retiree medical plans generally require the designation of a primary

care provider. You have the right to designate any primary care provider who participates in

the health plan’s network and who is available to accept you or your family members. Until

you make this designation, your HMO plan designates one for you. For information on how

to select a primary care provider, and for a list of the participating primary care providers,

contact:

Health Net Non‑Medicare HMO 1.800.522.0088

Health Net Medicare HMO 1.800.275.4737

UHC Non‑Medicare HMO 1.800.624.8822

UHC Medicare HMO 1.800.457.8506

For children, you may designate a pediatrician as the primary care provider. You do not need

prior authorization from Health Net or UHC or from any other person (including a primary

care provider) in order to obtain access to obstetrical or gynecological care from a health

care professional in the health plan’s network who specializes in obstetrics or gynecology.

The health care professional, however, may be required to comply with certain procedures,

including obtaining prior authorization for certain services, following a pre‑approved

treatment plan, or procedures for making referrals. For a list of participating health care

professionals who specialize in obstetrics or gynecology, contact your medical plan provider.


20

SDCERA-sponsored health insurance plans

Access to SDCERA‑sponsored health insurance plans is not a vested right or guaranteed benefit. The

County Employees Retirement Law of 1937 and the California Public Employees’ Pension Reform

Act of 2013 do not require SDCERA to provide any post‑retirement health insurance plans. The

Board of Retirement annually determines whether to continue the health insurance plans.

Woman’s Health and Cancer Rights Act of 1998

Your (or your dependent’s) health plan will not restrict benefits if you (or your dependent) received

benefits for a mastectomy and elected breast reconstruction in connection with a mastectomy.

Benefits will not be restricted provided the breast reconstruction is performed in a manner determined

in consultation with your (or your dependent’s) physician and may include: (1) reconstruction of the

breast on which the mastectomy was performed, (2) surgery and reconstruction of the other breast to

produce a symmetrical appearance and (3) prostheses and treatment of physical complications for all

stages of mastectomy, including lymphedemas. Benefits for breast reconstruction may be subject to

appropriate annual deductibles and coinsurance provisions that are consistent with those established

for other benefits under the plan.

Medical and dental plan descriptions contained in this booklet

This booklet provides only a summary of the medical and dental plans offered to retired Members

and their eligible dependents. Please refer to each plan’s evidence of coverage documents for exact

terms and conditions of coverage. If there is a discrepancy between this summary and the plan

documents, the plan documents will govern in all cases.


Strength. Service. Commitment.

SDCERA Retiree Health Program Service CenterPO Box 14464Des Moines, IA 50306‑34641.866.751.0256, Monday ‑ Friday 5:30 a.m. to 6:00 p.m. Pacific Time www.sdcera.org

81508 B11968 (9/17)

Documents

2018 Health Insurance Plans - ebview.com · 2018 Health Insurance Plans Who can enroll? for Retired Members Retired Members, surviving spouses/ partners, and eligible dependents When